As of 2022, the basic medical insurance reimbursement scope for urban and rural residents is as follows:
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I. Reimbursement scope of medicines
Reimbursement is made according to the "Catalogue of Medicines for Basic Medical Insurance, Worker's Compensation Insurance, and Maternity Insurance" (including 2373 kinds of western medicines, proprietary Chinese medicines, and ethnic medicines***, of which: Category B medicines 1817 kinds) standard reimbursement, divided into Category A and Category B, and adjusted periodically. Category A is fully included in the scope of reimbursement, and Category B is included in the scope of reimbursement after a certain percentage of out-of-pocket payment (10% out-of-pocket payment for Category B medicines, and 15% out-of-pocket payment for Category B medicines with a unit price of more than 100 yuan in the smallest package according to the special use of medicines).
Second, the scope of reimbursement of treatment items
Based on the "urban workers' basic medical insurance treatment items catalog" determined by the basic medical insurance is allowed to pay the cost, allowed to partially pay the cost and not pay the cost of the treatment items standard report failed to sell. Attached to the basic medical insurance diagnosis and treatment items catalog:
Basic medical insurance does not pay for the cost of diagnosis and treatment items
(a) service items:
1. Registration fee, consultation fee, consultation fee, outpatient consultation fee, remote consultation fee, medical guide service fee.
2. Expedited examination and treatment fee, name (booking) medical service fee, room inspection fee, self-employed special nurse fee, door-to-door service fee, discharge follow-up fee, mother and child system full service and other special medical service fee.
3. Labor cost of medical records, microcomputer inquiry and management fees, and labor cost of various bills.
(2) non-disease treatment items:
1. Various cosmetic treatments such as freckles, pimples, black spots, warts, acne, blemishes, pigmentation and alopecia (including baldness), white hair, nevus, piercing of the ears, saddle-nose, breast augmentation, single eyelid to double eyelid, massage and other cosmetic items.
2. All kinds of cosmetic, orthopedic (except the sequelae of poliomyelitis) and physical defects treatment, such as cut the fox odor, make up the hare lip, stuttering, correction of strabismus, cut more fingers (toes), circumcision, "O" pei shirt shaped legs, "X" shaped legs, refractive error, vision correction and other surgical projects.
3. Diabetes Decision Support System, Sleep and Respiration Monitoring System, Trace Element Detection, Bone Densitometry, Body Information Diagnosis, Computerized Selection of Optimal Pregnancy Period, Fetal Sex and Fetal Development Examination, and other diagnostic and therapeutic programs.
4. A variety of weight loss, fat gain, height increase, bodybuilding, smoking cessation treatment programs.
5. All kinds of health checkups. 6. All kinds of preventive health care treatment programs.
7. A variety of medical consultations (including psychological prediction, health prediction, dietary consultation, disease consultation), a variety of predictions (including stroke prediction, health prediction, disease prediction,) a variety of appraisal (forensic appraisal, industrial injury appraisal, labor appraisal, medical appraisal, paternity appraisal), health guidance and other projects.
(C) therapeutic equipment and medical materials:
1. Cell knife, positron emission segmented layer device PET, electron beam CT, ophthalmic excimer laser treatment instrument and other large medical equipment for the inspection and treatment program.
2. Eyeglasses, prosthetic eyes, prosthetic teeth, prosthetic limbs, hearing aids, brain fitness, leather (steel) undershirt, steel girth, steel head and neck, stomach support, kidney support, scrotum support, uterus support, crutches, wheelchairs, deformed insoles, pillows, pill pads, hot packs, pressure pulse belt, infusion net, testicular belt, hernia belt, knee strap, artificial anal bag and other appliances.
3. All kinds of home inspection detector (device), treatment instrument (device) physiotherapy instrument (device), massagers and magnetic therapy supplies and other therapeutic appliances.
4. The use of medical instruments, equipment and medical materials do not meet the national or provincial supervision of the management of medical instruments, equipment and medical materials for diagnosis and treatment programs.
5. Provincial price department regulations can not be charged separately for disposable medical materials.
(D) therapeutic project category:
1. Various types of organ or tissue transplantation of organ source or tissue source and access to organ source, tissue source of the relevant surgery, etc..
2. Transplantation of organs or tissues other than kidney, heart valve flap, cornea, skin, blood vessel, bone and bone marrow transplantation.
3. Prostate hyperplasia microwave (radiofrequency) treatment, helium-neon laser intravascular irradiation (hemotherapy), anesthesia and post-operative analgesia new technology (pain beds), endoscopic retrograde appendicography with withered cavities and other diagnostic and therapeutic items.
4. Dental veneers, dental implants, teeth, teeth, teeth, yellow and black teeth, dental defects, stained teeth, grilled magnetic teeth and other diagnostic and treatment programs.
5. Qigong therapy, music therapy, hypnotherapy, magnetic therapy, water bar therapy, oxygen bar therapy, positional therapy, psychotherapy and suggestive therapy (except for psychiatric patients), food therapy, nutritional therapy and other auxiliary treatment programs.
6. Various infertility (pregnancy), sexual dysfunction and family planning programs.
7. All kinds of scientific research, teaching, clinical verification of the treatment program.
Basic medical insurance to pay part of the cost of medical treatment
(A) diagnostic and treatment equipment and medical materials:
1. Application of r-knife, x-knife, x-ray computed tomography (CT), cardiac and angiography x-ray machine (including digital subtraction equipment), magnetic **** vibration imaging device (MRI), single-photon emission computerized scanning device (SPECT). device (SPECT), color Doppler, medical linear gas pedal and other large medical equipment for examination and treatment items.
2. Extracorporeal shock wave lithotripsy and hyperbaric oxygen therapy programs.
3. All kinds of clinical monitoring (except intraoperative and postoperative monitoring).
4. Disposable medical materials that can be charged separately as stipulated by the provincial price department.
(2) treatment program category:
1. Hemodialysis, peritoneal dialysis treatment program.
2. To carry out kidney, heart valve, cornea, skin, blood vessels, bone, bone marrow transplantation projects.
3. Pacemakers, artificial valves, artificial joints, artificial crystals, a variety of stents, a variety of anastomoses, a variety of catheters, implanted drug delivery devices and other internal replacement of artificial organs, materials and installation or placement of the body surgery program.
4. Heart bypass, cardiac catheterization balloon dilatation, cardiac radiofrequency ablation and other surgical projects.
5. Coronary angiography, laparoscopic and thoracoscopic surgery, cardiac laser perforation, tumor biotherapy T lymphocyte infusion method, prostate electrocision, tumor thermotherapy and other diagnostic and therapeutic projects.
6. Various kinds of microwave, spectrum, far-infrared rays, light quantum (liquid therapy) and other auxiliary treatment programs.
Legal basis:
The People's Republic of China Social Insurance Law
Article 27: Individuals participating in the basic medical insurance for employees who have reached the statutory retirement age and have accumulated a total of contributions for a period of time prescribed by the state, will no longer be required to pay the basic medical insurance premiums after retirement, and will be entitled to basic medical insurance benefits in accordance with the state regulations; individuals who have not reached the state's prescribed limit of contributions will be entitled to basic medical insurance benefits. treatment; if they have not yet reached the state's prescribed number of years, they may make contributions until the state's prescribed number of years.
Article 28 Medical expenses that conform to the basic medical insurance drug list, diagnostic and treatment items, standards of medical service facilities, as well as those for emergency treatment and rescue, shall be paid out of the basic medical insurance fund in accordance with the state regulations.
Article 29 The part of the medical expenses of the insured that should be paid by the basic medical insurance fund shall be settled directly between the social insurance administration organization and the medical institutions and drug business units.
The administrative departments of social insurance and the administrative departments of health shall establish a settlement system for medical expenses incurred for medical treatment in other places, so as to facilitate the enjoyment of basic medical insurance by insured persons.
Article 30 The following medical expenses shall not be included in the scope of payment by the basic medical insurance fund:
(1) those that should be paid from the workers' compensation insurance fund;
(2) those that should be borne by a third person;
(3) those that should be borne by the public ****health;
(4) those that seek medical treatment outside China.
Medical expenses shall be borne by a third person in accordance with the law, and if the third person fails to pay or if the third person cannot be identified, the basic medical insurance fund shall pay in advance. The basic medical insurance fund shall have the right to recover the costs from the third party after the first payment.